WAC 388-535-1070   Dental-related services provider information.  (1) The following providers are eligible to enroll with the medical assistance administration (MAA) to furnish and bill for dental-related services provided to eligible clients:

     (a) Persons currently licensed by the state of Washington to:

     (i) Practice dentistry or specialties of dentistry.

     (ii) Practice as dental hygienists.

     (iii) Practice as denturists.

     (iv) Practice anesthesia by:

     (A) Providing conscious sedation with parenteral or multiple oral agents, deep sedation, or general anesthesia as an anesthesiologist or dental anesthesiologist;

     (B) Providing conscious sedation with parenteral or multiple oral agents, deep sedation, or general anesthesia as a certified registered nurse anesthetist (CRNA) under WAC 246-817-180; or

     (C) Providing conscious sedation with parenteral or multiple oral agents as a dentist, when the dentist has a conscious sedation permit issued by the department of health (DOH) that is current at the time the billed service(s) is provided; or

     (D) Providing deep sedation or general anesthesia as a dentist when the dentist has a general anesthesia permit issued by DOH that is current at the time the billed service(s) is provided.

     (v) Practice medicine and osteopathy for:

     (A) Oral surgery procedures; or

     (B) Providing fluoride varnish under EPSDT.

     (b) Facilities that are:

     (i) Hospitals currently licensed by the DOH;

     (ii) Federally-qualified health centers (FQHCs);

     (iii) Medicare-certified ambulatory surgical centers (ASCs);

     (iv) Medicare-certified rural health clinics (RHCs); or

     (v) Community health centers.

     (c) Participating local health jurisdictions.

     (d) Bordering city or out-of-state providers of dental-related services who are qualified in their states to provide these services.

     (2) Subject to the restrictions and limitations in this section and other applicable WAC, MAA pays licensed providers participating in the MAA dental program for only those services that are within their scope of practice.

     (3) For the dental specialty of oral and maxillofacial surgery:

     (a) MAA requires a dentist to:

     (i) Be currently entitled to such specialty designation (to perform oral and maxillofacial surgery) under WAC 246-817-420; and

     (ii) Meet the following requirements in order to be reimbursed for oral and maxillofacial surgery:

     (A) The dentist must have participated at least three years in a maxillofacial residency program; and

     (B) The dentist must be board certified or designated as "board eligible" by the American Board of Oral and Maxillofacial Surgery.

     (b) A dental provider who meets the requirements in (3)(a) of this section must bill claims using appropriate current dental terminology (CDT) codes or current procedural terminology (CPT) codes for services that are identified as covered in WAC and MAA's published billing instructions or numbered memoranda.

     (4) See WAC 388-502-0020 for provider documentation and record retention requirements. MAA requires additional dental documentation under specific sections in this chapter and as required by chapter 246-817 WAC.

     (5) See WAC 388-502-0100 and 388-502-0150 for provider billing and payment requirements. Enrolled dental providers who do not meet the conditions in (3)(a) of this section must bill all claims using only the CDT codes for services that are identified in WAC and MAA's published billing instructions or numbered memoranda. MAA does not reimburse for billed CPT codes when the dental provider does not meet the requirements in subsection (3)(a) of this section.

     (6) See WAC 388-502-0160 for regulations concerning charges billed to clients.

     (7) See WAC 388-502-0230 for provider review and appeal.

     (8) See WAC 388-502-0240 for provider audits and the audit appeal process.



[Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. 05-06-092, § 388-535-1070, filed 3/1/05, effective 4/1/05. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 2003 1st sp.s. c 25, P.L. 104-191. 03-19-077, § 388-535-1070, filed 9/12/03, effective 10/13/03. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.500, 74.09.520, 42 U.S.C. 1396d(a), 42 C.F.R. 440.100 and 440.225. 02-13-074, § 388-535-1070, filed 6/14/02, effective 7/15/02.]